ABSTRACT

Context Few studies document how parents adapt to the
experience of a very low-birth-weight (VLBW; <1500 g) birth despite
societal concerns about the ethics and justification of intensive care
for these infants.

Objective To determine the degree and type of stress experienced
over time by mothers whose infants vary in degree of prematurity and
medical and developmental risk.

Design Longitudinal prospective follow-up study of a cohort of
mothers of high- and low-risk VLBW and term infants from birth to 3
years.

Participants Mothers and infants prospectively and
consecutively enrolled in a longitudinal study between 1989 and 1991.
High-risk VLBW infants were diagnosed as having bronchopulmonary
dysplasia, and comparison groups were low-risk VLBW infants without
bronchopulmonary dysplasia and term infants (>36 weeks, >2500 g).

Results Mothers of VLBW infants (high risk, n=122; low
risk, n=84) had more psychological distress than mothers of term
infants (n=123) at 1 month (13% vs 1%; P=.003). At 2
years, mothers of low-risk VLBW infants did not differ from term
mothers, while mothers of high-risk infants continued to report
psychological distress. By 3 years, mothers of high-risk VLBW children
did not differ from mothers of term children in distress symptoms,
while parenting stress remained greater. Severity of maternal
depression was related to lower child developmental outcomes in both
VLBW groups.

Conclusions The impact of VLBW birth varies with child medical
risk status, age, and developmental outcome. Follow-up programs should
incorporate psychological screening and support services for mothers of
VLBW infants in the immediate postnatal period, with monitoring of
mothers of high-risk VLBW infants.

Figures in this Article

Very
low-birth-weight (VLBW; <1500 g) birth has become an increasingly
common occurrence because of medical advances in neonatal intensive
care and management of high-risk pregnancy. Approximately 50,000
VLBW births occur annually in the United States.1
Significant improvements have occurred in survival rates of small
preterm infants, especially those of extremely low birth weight (ie,
<1000 g). However, follow-up studies of survivors have documented
higher rates of neurodevelopmental impairment, including motor, visual,
and hearing disabilities; mental retardation; attention disorders; and
learning disabilities at school age in comparison with term
infants.2- 6 Increased rates of disability among survivors
have engendered debate about the ethics and justification of intensive
care for the most immature infants.7 Although the birth of
an infant with VLBW poses a considerable challenge to parents, there is
little information detailing how they adapt to this experience and
subsequent caregiving demands.

Mothers of preterm infants experience more severe levels of
psychological distress in the neonatal period than mothers of full-term
infants,8,9 with depression and anxiety notable at the time
of hospital discharge,8- 11 but there have been few
controlled studies beyond this period. In studies of healthy term
infants, maternal depression has been
linked to negative effects on child cognitive,
emotional, and behavioral development.12- 14 Early maternal
depression or other psychological distress symptoms may have
differential effects on preterm infants.15,16 The
relationship of maternal mental health to parenting behavior is
important to investigate prospectively in preterm populations because
maternal psychological status has been found to correlate with
childhood emotional and mental well-being at school age in
low-birth-weight and preterm children.4

Parenting strains may also be exacerbated for mothers of preterm
infants.8,17 Greater caregiver burdens in parents of
preterm infants have been related to the severity of neonatal medical
complications that make daily parenting tasks more time-consuming and
difficult,18 although not all findings are consistent. In a
Canadian survey19 of parents of young preschool children
with VLBW, even those parents whose children with VLBW had cognitive
delays reported no greater personal, family, or financial strains than
parents of term children, while parents of normally developing children
with VLBW actually reported less negative family and personal impact
than the reference group of parents of healthy term children.

However, such cross-sectional studies may obscure the effects of
age-related parenting strains, which can affect maternal mental health.
Also, few prior studies on the family impact of VLBW birth have
included controlled comparison groups, which are important because
psychosocial sequelae may be related to other factors associated with
VLBW birth, such as low socioeconomic status,20 maternal
substance abuse,21 multiple birth, or other life
stressors.22

We longitudinally followed up mothers of prospectively recruited
cohorts of high- and low-risk infants with VLBW and a comparison cohort
of term infants until 3 years of age, measuring maternal psychological
distress, perception of parenting stress, family impact, and concurrent
life stressors at multiple age points.

METHODS

Mothers were interviewed as part of a longitudinal study of the
outcomes of infants with bronchopulmonary dysplasia (BPD) and
VLBW.23 Infants with VLBW admitted to the neonatal
intensive care units of hospitals in the Cleveland, Ohio, region were
eligible for the study and were prospectively and consecutively
enrolled between 1989 and 1991 at birth.

High-risk infants with VLBW were defined as those with all of the
following: (1) diagnosis of BPD, (2) birth weight of less than 1500 g,
(3) supplementary oxygen requirement for more than 28 days because of
lung immaturity at birth, and (4) radiographic evidence of chronic lung
disease.24,25 A partial stratification sampling strategy
was adopted to enroll adequate numbers of subjects without
socioeconomic disadvantage or severe neurologic risk so the impact of
social class and medical risk factors on outcome could be investigated.
Infants diagnosed as having BPD who were free of neurologic problems
other than grade I or II intraventricular hemorrhage and who were not
socially disadvantaged (ie, Hollingshead classification IV or
V)26 were exhaustively recruited. The remainder was
recruited by approaching the family of the next available infant with
BPD who could be accommodated in the follow-up schedule. Parents of
infants with BPD were approached by a research assistant in the
hospital as soon as possible after the diagnosis of BPD was made by the
attending neonatologist. Parents were informed that the longitudinal
study was investigating the outcomes and family stressors associated
with BPD and VLBW.

Low-risk infants with VLBW did not have a diagnosis of BPD, were
preterm, weighed less than 1500 g at birth, and required oxygen
supplementation for less than 14 days. For each infant with BPD, the
next available comparison infant with VLBW and without BPD who was of
the same race and socioeconomic status and born during the same period
was recruited.

As a control group, term infants were recruited from the neonatal
nurseries. Term infants had no diagnosed medical illnesses or
abnormalities at birth, were more than 36 weeks' gestational age, and,
for singleton births, weighed more than 2500 g at birth. Information
about the study and return-addressed postcards were provided to all
mothers in the term nurseries. For each infant with BPD enrolled, the
next eligible term infant equivalent in race and socioeconomic status
with a returned postcard indicating parental willingness to participate
was recruited.

For all groups, infants with major congenital malformations or
drug exposure or whose mothers had major psychiatric or physical
illness, human immunodeficiency virus, or mental retardation or who
lived more than 2 hours' driving distance were excluded. Other details
of recruitment and information regarding attrition and medical risk
status have been previously reported.23 More than 91% of
survivors recruited were seen for at least 1 follow-up visit. Follow-up
rates at each age ranged from 83% to 89% for the high-risk VLBW
group, 64% to 88% for the low-risk VLBW group, and 85% to 90% for
the term group.

Procedures

Mothers completed the following standardized self-report measures at 1,
8, and 12 months and 2 and 3 years (ages corrected for prematurity).

2. The Parenting Stress Index (PSI)29 assesses
parental perceptions of the degree
of stress related to dimensions of the parenting
role. The parent domain measures 6 dimensions of stress, ie,
reinforcement of parent, depression, role restriction, sense of
competence, social isolation, and spousal/boyfriend support. Under the
child domain, child characteristics of adaptability, acceptability,
distractibility-hyperactivity, mood, attachment, and reinforcement to
parent are rated. Normative data from the PSI were derived from 534
families of children aged 1 month to 19 years seen in a pediatric
setting. The PSI has acceptable reliability and demonstrated validity
in studies of parents of sick children.30,31

3. The Impact on Family Scale,32 given at 2 and 3 years,
measures maternal perceptions of the child's impact on the family.
Designed to assess the impact of a child with a disability, statements
were modified to also apply to healthy children. The scale assesses
financial and personal strains; disruption of family, social and
sibling relations; and mastery (coping) abilities in 5 subscales that
can be summed to a total score. Prior studies have demonstrated the
reliability and validity of the scale.18,19,32,33

4. The Family Inventory of Life Events and Changes
(FILE)34 assesses the family's experience of a variety of
life changes during the previous year. It documents the occurrence or
nonoccurrence of family life changes conceptualized as stressful in 9
categories: intrafamily strains, marital strains, pregnancy and
childbearing strains, finance/business strains, work-family
transitions, illness, losses, transitions, and family legal violations.
The FILE served to determine whether group differences in life
stressors, other than infant illness and prematurity, could account for
maternal psychological, parenting, or family strains.

At 8 months and each subsequent visit, all infants were administered
the Bayley Scales of Infant Development.35,36 Results from
the mental scale yield the Mental Development Index (MDI), a standard
score reflecting overall cognitive development.

This study was approved by the institutional review boards of the
hospitals that participated and written informed consent was obtained
for all subjects.

Data Analyses

For cases in which distributions were significantly skewed, scores were
normalized using logarithm (x + 1) transformations prior to data
analysis. Group differences and changes over time for the BSI, PSI, and
FILE were examined using a mixed-models approach with restricted
maximum likelihood estimation procedures. PROC from SAS, Version 6.12,
was used.37

For the Impact on Family Scale, repeated-measures analyses of variance
were used. Incidence of clinically significant symptoms of moderate or
severe general distress, depression, and other symptoms from the BSI
were also compared by group for each point.

Spearman rank-order correlations were computed to assess the
relationship of severity of maternal psychological symptoms with child
outcome (Bayley MDI) at each point.

RESULTS

Sample Characteristics

As reported previously,23 high-risk infants with VLBW had
lower birth weight and gestational age, with more neurologic and
medical risk factors and significantly lower standard scores on the
Bayley mental scale than low-risk infants with VLBW and term infants (Table 1). Bayley standard scores were
in the mentally retarded range (<70) for 18% to 21% of the
high-risk VLBW group at each age, 6% to 11% of the low-risk VLBW
group, and less than 5% of the term group (F score >13.1 for all;
P<.001 for all), supporting the validity of the
classification of risk status.

Groups did not differ in race, social class, sex, or maternal
educational or marital status. There was a higher percentage of
multiple births and a larger family size at 3 years in the low-risk
VLBW group than in the other 2 groups.

Maternal Psychological Distress

During the 3-year study, mothers of high-risk infants with VLBW
reported higher levels of psychological distress than mothers of
low-risk infants with VLBW and term infants, especially depression,
anxiety, and obsessive-compulsive behaviors, but the severity of these
symptoms varied over time (Figure 1).

GSI indicates General Severity Index. All scores had
significant group effects (P<.001) and group-by-time
interactions (P=.05). High-risk very low-birth-weight (VLBW)
scores differed significantly over time from low-risk VLBW and term
scores in post hoc comparisons. For GSI scores, at birth, high risk are
higher than term (t=2.7; P=.007); at 2 years,
high risk are higher than low risk (t=2.4; P=.02)
and high risk are higher than term (t=1.9; P=.06); and at 3 years, high risk are higher than low risk (t=2.6; P=.01) and high risk are
higher than term (t=1.7; P=.10). For depression scores, at birth, high risk are
higher than term (t=2.5; P=.01); at 2 years, high
risk are higher than low risk (t=2.4; P=.02); and
at 3 years, high risk are higher than low risk (t=1.7; P=.09). For anxiety, at birth, high risk are higher
than term (t=3.5; P<.001); at 8 months, high risk
are higher than term (t=1.9; P=.05); at 12
months, high risk are higher than low risk (t=1.9;
P=.06); at 2 years, high risk are higher than term
(t=1.9; P=.06); and at 3 years, high risk are
higher than low risk (t=2.2; P=.03). For
obsessive-compulsive scores, at birth, high risk are higher than term
(t=3.2; P=.002); at 2 years, high risk are
higher than low risk (t=2.2; P=.03) and high
risk are higher than term (t=1.8; P=.08); and
at 3 years, high risk are higher than low risk (t=2.5;
P=.01) and high risk are higher than term
(t=2.1; P=.03).

At infant age of 1 month, the mean scores of mothers of
high-risk infants with VLBW were higher on dimensions of general
psychological distress, anxiety, depression, and obsessive-compulsive
behaviors than those of mothers of term infants, while those of mothers
of low-risk infants with VLBW
were halfway between mothers of high-risk and
term infants, supporting the notion that higher levels of child risk
were related to severity of maternal psychological distress. Nine
percent of mothers of both high- and low-risk infants with VLBW
reported severe symptoms (ie, >98th percentile for female norms) of
depression (χ2=5.6; P=.02) and 13% of
mothers of both high- and low-risk infants reported severe symptoms of
overall distress compared with 1% of term mothers (χ2=8.8; P=.003). Less severe but clinically significant
symptoms of general distress were reported by 32% of mothers of
high-risk and 29% of mothers of low-risk infants with VLBW in contrast
with 17% of mothers of term infants. Mothers of both groups of infants
with VLBW were also more likely to experience moderately elevated
symptoms in the domains of obsessive-compulsive behavior (39% high
risk vs 27% low risk vs 15% term; χ2=10.9;
P<.001) and anxiety (26% high risk vs 23% low risk vs 7%
term; χ2=9.5; P=.002).

By infant ages of 8 and 12 months, there were no differences among
groups and all scores were within normative ranges, with the exception
that more mothers of high-risk infants with VLBW continued to have
clinically significant symptoms of anxiety at 8 months (20% high risk
vs 4% low risk vs 6% term; χ2=7.7;
P=.02).

However, at 2 years, mothers of high-risk infants with VLBW were more
likely to report symptoms of moderate but clinically significant
depression than mothers of low-risk infants with VLBW (24% high risk
vs 0% low risk vs 10% term; Fisher exact test, P=.006)
as well as clinically higher levels of general distress than mothers of
term infants (24% high risk vs 0% low risk vs 13% term; Fisher exact
test, P=.03). By 3 years, there were no differences among
the 3 groups of mothers in clinical incidence of psychological distress
symptoms.

Parenting Stress

The PSI child domain score indicated significantly higher stress for
mothers of high-risk infants with VLBW compared with mothers of term
infants at 1 and 3 years, reflecting that they perceived their children
as more distractible, hyperactive, and demanding than did mothers of
term infants (Figure 2). However,
high-risk children with VLBW were not perceived as less acceptable,
less attached, or less reinforcing than low-risk children with VLBW or
term children. Mothers of low-risk children with
VLBW did not perceive their children as more
stressful than did mothers of term children on any dimension.

There was an overall group effect (F=3094; P<.001)
with a group-by-time interaction (F=3.9; P=.008).
High-risk very low-birth-weight (VLBW) scores differed significantly
over time from term scores (t=2.1; P=.03) in post
hoc comparisons.

The PSI parent domain scores did not differ among mothers at any time.
Mothers of high- and low-risk infants with VLBW experienced levels of
partner or spousal support and general support equivalent to mothers of
term infants, as well as equivalent feelings of parenting competence.

Family Impact

More family stress was experienced by mothers of high- and low-risk
infants with VLBW compared with mothers of term infants at 2 years (Figure 3). At 2 years, mothers of
both high- and low-risk infants with VLBW reported greater financial
stress than mothers of term infants, but only mothers of high-risk
infants with VLBW reported greater family stress, more personal strain,
and higher overall stress. There were no differences in coping mastery
among the 3 groups of mothers, indicating that all mothers endorsed
similar positive feelings of accomplishment related to parenting. By 3
years, however, the stressors experienced by mothers of low-risk
infants with VLBW had diminished to levels similar to mothers of term
infants on all dimensions, while mothers of high-risk infants with VLBW
continued to report greater financial, family, personal, and total
stress scores.

Figure 3. Mean Number of Stressors in the Family Inventory of
Life Events

VLBW indicates very low birth weight. There were significant
effects for the subscale of illness for group (F=99.1;
P=.04) and for the group-by-time interaction (F=2.78;
P<.05). For the pregnancy subscale, there was also a
significant group-by-time interaction (F=11.0;
P<.001).

Life Stressors

The number of infant illness and pregnancy stressors differed over time
for families with high- and low-risk infants with VLBW or term infants,
indicating that the classification of high and low medical risk was
valid (Figure 4). There were more
pregnancy stressors for the families of high-risk infants neonatally
compared with families who had term infants, indicating that they
reported more experiences of a difficult pregnancy in the previous
year. By 3 years, however, there were more pregnancy stressors reported
in the families of term infants compared with families with high-risk
infants, indicating more experiences with pregnancy in the prior year,
either through birth, adoption, abortion, or a difficult pregnancy.
Families did not differ on financial stressors, life transitions,
losses, or legal or work-related events in the year prior to infant
birth or during the course of the study that might influence maternal
distress symptoms independent of VLBW birth.

Figure 4. Mean Scores on Subscales Within the Impact on Family
Scale

VLBW indicates very low birth weight. There was an overall group
effect (P<.05) for the family/social (F=4.4; P=.04) and personal (F=4.2; P=.04) strain subscales and a
trend for the financial subscale (F=3.0; P=.09).
There was a group-by-time interaction effect (P<.05) for the
family/social (F=4.0; P=.05) and financial (F=3.5;
P=.07) subscales.

Multiple VLBW Births

When the same comparisons of stressors and distress symptoms
experienced by mothers of high- and low-risk infants with VLBW were
analyzed for mothers whose infants with VLBW were multiple births, the
findings were similar. There was no evidence for greater maternal
stress on any of the dimensions measured based on multiple-birth
status. Moreover, the lowest levels of stress after the neonatal period
were experienced by the low-risk VLBW group, which had greater parity,
more multiple births, and greater family size, suggesting that
high-risk status was a more important factor in maternal distress.

Relationship of Maternal Depression and Child Outcome

Correlations were examined between concurrent maternal depression
scores
on the BSI and Bayley MDI scores at each age for
the VLBW and term groups. Significant negative relationships between
severity of maternal depression and child mental outcomes were found
within the VLBW group, with correlations of −0.31, −0.27, −0.22, and
−0.33 (P<.05 for all) at 8, 12, 24, and 36 months,
respectively. For the term group, in which only a few children
functioned at below-normal levels, there were no significant
relationships between severity of maternal depression and child mental
functioning, with correlations of −0.10, −0.15, −0.11, and 0.10 for
the same ages.

COMMENT

The results of this longitudinal study indicate that the
psychosocial impact of VLBW birth varies dependent on the medical risk
status, age, and developmental outcome of the infant. In terms of
maternal mental health symptoms, mothers of both high- and low-risk
infants with VLBW had similar initial responses, with elevated levels
of psychological distress neonatally, but had few differences from
mothers of term infants by 8 and 12 months. During the neonatal period,
symptoms of depression, anxiety, and obsessive-compulsive behaviors,
including difficulty concentrating and making decisions, were
prominent.

A surprising finding was that mothers of low-risk infants with VLBW
were similar after the neonatal period to mothers of term infants on
all measures and, by 3 years, had the lowest levels of distress.
Because low-risk infants with VLBW performed within normative ranges at
follow-up and because maternal distress was related to poorer child
outcome, it is possible that these mothers' relatively low distress
levels were due to maternal relief after an initial period of fear and
anxiety.

Mothers of high-risk infants with VLBW, in contrast, had a
more complicated course, with more symptoms of distress at 2 years,
more negative family impact at 2 and 3 years, and more parenting
strains and illness stressors at 3 years. Yet, by 3 years, their
reported psychological distress was not different from term mothers and
parenting satisfaction was similar, except that mothers of high-risk
infants with VLBW regarded their children as more demanding. These
mothers' positive feelings of mastery were also equivalent to those
reported by mothers of term infants and mothers of low-risk infants
with VLBW.

The recurrence of elevated symptoms of distress for mothers of
high-risk infants with VLBW at 2 years may reflect the opposite of the
process that occurred for mothers of low-risk infants with VLBW. By 2
years, infant developmental scores are predictive of later outcomes,
and many mothers of high-risk infants with VLBW must relinquish their
hopes for their children to "catch up" to term infants
developmentally, with accompanying symptoms of psychological distress.
The finding that these symptoms for mothers of high-risk infants with
VLBW are not different from those of term mothers by 3 years suggests
some psychological adaptation despite continued maternal acknowledgment
of greater family and parenting stressors. At 3 years, mothers of term
infants reported experiencing more pregnancy-related events in the
prior year than mothers of high-risk infants with VLBW. This finding
suggests that parents of high-risk infants with VLBW may wait longer to
try to have more children.

The current findings confirm results from smaller cross-sectional
studies of significant psychological distress8- 10 in
postpartum mothers of infants with VLBW, as well as positive family
adaptation and parenting satisfaction, even for mothers of high-risk
infants with VLBW by 3 years.18

In contrast with prior studies, our cohort was regional, prospectively
recruited, and followed up longitudinally. Furthermore, the cohort
included a racially and socioeconomically diverse sample in which
important confounding factors were controlled and multiple dimensions
of parenting stress and mental health were assessed. Thus, the bias of
hospital-based selection was avoided and assessment of age-related
changes in stress could be accurately evaluated. In particular, life
event stressors other than those associated with VLBW birth did not
differ among the groups in the year prior to or at birth.

However, our findings may not generalize to fathers of infants with
VLBW, who may experience different parenting stressors. Another
limitation is the reliance on parental perceptions of family impact
rather than direct measurement of family and maternal functioning.
Subjective reports of well-being, however, are an important measure of
life satisfaction. Finally, the small sample of multiple births may
have precluded detection of differences for that group.

These findings have implications for health care policy, given some
concerns that the increased survival of very small infants with VLBW
and neurodevelopmental disabilities may lead to intolerable family
burden.38,39 Symptoms of psychological distress,
satisfaction with parenting, attachment to their children, and positive
feelings of coping and mastery in mothers of high- and low-risk infants
with VLBW were not different from those reported by mothers of term
children by 3 years, even in the group with the highest rate of severe
disabilities. These positive findings are congruent with other studies
that found satisfactory quality of life self-reported by teenage
survivors of VLBW40 and positive attitudes toward saving
high-risk infants with VLBW in parents of children who had VLBW
births.41

These findings further suggest that current VLBW follow-up programs
might benefit from the addition of psychological and family services
into traditional neurodevelopmental assessment programs, particularly
in the neonatal period and at infant age of 2 years. Despite the
overall positive adaptation of mothers by 3 years, 10% of mothers of
infants with VLBW reported severe symptoms of psychological distress
neonatally—5-fold the rate for term mothers—while almost one third of
mothers of infants with VLBW had clinically meaningful levels of
depression and anxiety. For mothers of high-risk infants with VLBW,
significant symptoms recurred at infant age of 2 years. The neonatal
period affords an opportunity to identify mothers who are most at risk
with standardized, simple screening techniques.27 Such
identification and
referral for treatment may prevent the development of
more severe symptoms, which can interfere with effective
parenting,13,16 while the provision of social supports may
also effectively buffer distress.9,42,43

GSI indicates General Severity Index. All scores had
significant group effects (P<.001) and group-by-time
interactions (P=.05). High-risk very low-birth-weight (VLBW)
scores differed significantly over time from low-risk VLBW and term
scores in post hoc comparisons. For GSI scores, at birth, high risk are
higher than term (t=2.7; P=.007); at 2 years,
high risk are higher than low risk (t=2.4; P=.02)
and high risk are higher than term (t=1.9; P=.06); and at 3 years, high risk are higher than low risk (t=2.6; P=.01) and high risk are
higher than term (t=1.7; P=.10). For depression scores, at birth, high risk are
higher than term (t=2.5; P=.01); at 2 years, high
risk are higher than low risk (t=2.4; P=.02); and
at 3 years, high risk are higher than low risk (t=1.7; P=.09). For anxiety, at birth, high risk are higher
than term (t=3.5; P<.001); at 8 months, high risk
are higher than term (t=1.9; P=.05); at 12
months, high risk are higher than low risk (t=1.9;
P=.06); at 2 years, high risk are higher than term
(t=1.9; P=.06); and at 3 years, high risk are
higher than low risk (t=2.2; P=.03). For
obsessive-compulsive scores, at birth, high risk are higher than term
(t=3.2; P=.002); at 2 years, high risk are
higher than low risk (t=2.2; P=.03) and high
risk are higher than term (t=1.8; P=.08); and
at 3 years, high risk are higher than low risk (t=2.5;
P=.01) and high risk are higher than term
(t=2.1; P=.03).

There was an overall group effect (F=3094; P<.001)
with a group-by-time interaction (F=3.9; P=.008).
High-risk very low-birth-weight (VLBW) scores differed significantly
over time from term scores (t=2.1; P=.03) in post
hoc comparisons.

Figure 3. Mean Number of Stressors in the Family Inventory of
Life Events

VLBW indicates very low birth weight. There were significant
effects for the subscale of illness for group (F=99.1;
P=.04) and for the group-by-time interaction (F=2.78;
P<.05). For the pregnancy subscale, there was also a
significant group-by-time interaction (F=11.0;
P<.001).

Figure 4. Mean Scores on Subscales Within the Impact on Family
Scale

VLBW indicates very low birth weight. There was an overall group
effect (P<.05) for the family/social (F=4.4; P=.04) and personal (F=4.2; P=.04) strain subscales and a
trend for the financial subscale (F=3.0; P=.09).
There was a group-by-time interaction effect (P<.05) for the
family/social (F=4.0; P=.05) and financial (F=3.5;
P=.07) subscales.

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